Participant Info Form - Summer Camp 2023

2023 SUMMER CAMP BOOKING FORM

Please read and complete the required Covid-19 waiver by clicking the button.

Once complete, proceed filling out the participation registration and

medical information below in order to proceed to payment

GO TO WAIVER

PARTICIPANT REGISTRATION & MEDICAL FORM

Please confirm your selected camp:

Legends of Summer Baseball Camp

Stars of Summer Softball Camp

Adult Participant/Parent Name

Birth Date

Home Address

Phone

Alt. Phone (Emergency/Cell Phone)

Minor Participant Name (Type "N/A" if non-applicable)

Sex

Birth Date

MEDICAL INSURANCE INFORMATION

Insurance Company Name

Group or Policy Number

Policy Holder's Name

MEDICATION

Medication(s) needed by a camper may be administered by a properly licensed healthcare professional or distributed by Program Staff for self-administration by the Minor under the following conditions: (a) parent/legal guardian must provide written authorization, (b) parent/legal guardian must provide the medicine in its original labeled pharmacy container for prescription medication or in the manufacturer’s container for over-the counter medications along with the camper’s name, medicine name, dosage and timing of consumption for prescription medication, (c) medicine should be kept in an appropriate and secure location, (d) a record showing the date, time, and signature of the person who administered or witnessed each self-administration of medicine must be kept for 90 days, (e) any medicine the camper cannot self-administer must be stored and administered by a licensed healthcare professional associated with the campus, or if no one is available, arrangements must be made with another healthcare professional in advance of the participant’s arrival, (f) personal “epipens and inhalers may be carried by the participant during activities.

This camper takes NO medications on a routine basis

This camper takes medications as follows (attach additional pages if needed)

Medication Name & Strength:

Dosage:

Times taken each day:

Reason for taking:

Medication Name & Strength:

Dosage:

Times taken each day:

Reason for taking:

Medication Name & Strength:

Dosage:

Times taken each day:

Reason for taking:

Medication Name & Strength:

Dosage:

Times taken each day:

Reason for taking:

PARENT AUTHORIZATION FOR MEDICATION:

I give permission for my child to take the above listed medication(s) as directed on the packaging and give permission for the medication(s) to be administered to my child by Next9Up personnel as needed according to the instructions provided.

**Parent or Guardian’s Signature

Date

**NOTE: Signature required only for those with medication(s) in their possession while attending camp.

ALLERGIES

No known allergies

This participant is allergic to: (see below)

To foods (list here):

Reaction:

To medications (list here):

Reaction:

To the environment/other (Insect stings, hay fever, etc. (list here):

Reaction:

PARENT AUTHORIZATION & PERMISSION TO TREAT:

*The above provided medical history is correct to the best to my knowledge and I give permission for the Next9Up staff to administer first aid and/or to provide the appropriate transportation to a medical facility to receive adequate medical care in the event of any injury or illness.

Signature of Parent/Guardian

Date

All campers are required to provide the latest copy of their physical and immunization history. These can be emailed to dryan14@next9up.com or brought on the first day of camp.

PARENT/GUARDIAN EMERGENCY CONTACT INFORMATION (To be contacted in event of illness or injury)

Parent/Guardian Name

Home Address

Relationship to child

City/State/Zip

Preferred Phone

Second Parent/Guardian Name

Relationship to child

Preferred Phone

NEXT9UP CAMPER PICKUP RELEASE

I give permission for my child to be released from Next9Up's baseball/softball clinic and/or received at the end of camp to the following people:

Camper's Name

Name

Home Address

Relationship to child

City/State/Zip

Preferred Phone

Name

Home Address

Relationship to child

City/State/Zip

Preferred Phone

Name

Home Address

Relationship to child

City/State/Zip

Preferred Phone

Please note if there is an existing restraining order or any specific instructions that we should be aware of:

We will not release your child to anyone that is not on the list without verifiable written instructions from the child’s legal guardian. Upon a child’s pickup, picture identification will be required for verification.

Signature of Parent/Guardian

Date

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AND PARENTAL CONSENT AGREEMENT

("AGREEMENT")

IN CONSIDERATION of being permitted to participate in any way in Next9Up, activities ("Activities") I, for myself for personal representatives, assigns, heirs, and next of kin:

1. ACKNOWLEDGE, agree, and represent that I understand the nature of Next9Up Activities (which includes promotional videos and pictures) and that I am qualified, in good health, and in proper physical condition to participate in such Activities. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.

2. FULLY UNDERSTAND THAT: (a) Next9Up ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISK AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the Activity.

3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE Next9Up, their respective administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owner and lessors of premises on which the Activity takes place, (each considered one of the "RELEASES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which may incur as the result of such claim.

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

Signature of Parent/Guardian

Date

MINOR RELEASE

AND I, THE MINOR’S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF NEXT9UP ACTIVITIES AND THE MINOR’S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEE’S FROM ALL LIABILITY CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR’S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATION AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE, I, THE MINOR, OR ANYONE ON THE MINOR’S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL INDEMNITY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.

I declare that the info I’ve provided is accurate & complete

Signature of Parent/Guardian

Date

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